F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016

REVIEW
Recent advances in the treatment of hip fractures in the elderly
[version 1; referees: 2 approved]
Joshua C. Rozell1, Mark Hasenauer1, Derek J. Donegan1, Mark Neuman2
1Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
2Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA

First published: 11 Aug 2016, 5(F1000 Faculty Rev):1953 (doi: Open Peer Review
v1 10.12688/f1000research.8172.1)
Latest published: 11 Aug 2016, 5(F1000 Faculty Rev):1953 (doi:
10.12688/f1000research.8172.1) Referee Status:

Abstract Invited Referees

The treatment of hip fractures in the elderly represents a major public health 1 2
priority and a source of ongoing debate among orthopaedic surgeons and
anesthesiologists. Most of these injuries are treated with surgery in an
version 1
expedient fashion. From the surgical perspective, there are certain special published
considerations in this population including osteoporosis, pre-existing arthritis, 11 Aug 2016
age, activity level, and overall health that contribute to the type of surgical
fixation performed. Open reduction and internal fixation versus arthroplasty
remain the two major categories of treatment. While the indications and F1000 Faculty Reviews are commissioned
treatment algorithms still remain controversial, the overall goal for these from members of the prestigious F1000
patients is early mobilization and prevention of morbidity and mortality. The use Faculty. In order to make these reviews as
of preoperative, regional anesthesia has aided in this effort. The purpose of this
comprehensive and accessible as possible,
review article is to examine the various treatment modalities for hip fractures in
the elderly and discuss the most recent evidence in the face of a rapidly aging peer review takes place before publication; the
population. referees are listed below, but their reports are
not formally published.

1 Stephen Kates, Virginia Commonwealth

University Health System USA

2 Ian Moppett, The University of Nottingham

UK

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 F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016

Corresponding author: Joshua C. Rozell (joshua.rozell@uphs.upenn.edu)

How to cite this article: Rozell JC, Hasenauer M, Donegan DJ and Neuman M. Recent advances in the treatment of hip fractures in the
elderly [version 1; referees: 2 approved] F1000Research 2016, 5(F1000 Faculty Rev):1953 (doi: 10.12688/f1000research.8172.1)
Copyright: © 2016 Rozell JC et al. This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Competing interests: The authors declare that they have no competing interests.
First published: 11 Aug 2016, 5(F1000 Faculty Rev):1953 (doi: 10.12688/f1000research.8172.1)

F1000Research
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Introduction
The overall trend in hip fractures in the US has shown a decline
over the past 10 years. Despite the rise in the aging population with
a simultaneous increase in activity level, the use of bisphosphonates
and decreased use of estrogens have contributed to this change,
especially in women1. In the global arena, hip fracture rates in Japan
and China have risen because of an increase in the elderly popula-
tion as well as lifestyle changes related to urbanization, and hip
fractures in women occur at the highest rate in Norway, Sweden,
Denmark, and Austria2. However, it is estimated that by 2030 the
prevalence of hip fractures will increase to 289,000 per year nation-
ally, making these injuries a significant public health concern. Spe-
cifically, the number of hip fractures among men is projected to
increase by 52%. By 2050, there will be an estimated 3.9 million
hip fractures worldwide and 700,000 in the US3, amounting to over
$15 billion per year in medical costs4. Some compounding reasons
for this relative rise are that the percentage of people older than
65 years old will increase by over 80%5 and that 90% of hip fractures
occur in patients older than 65 years old6. In a sampling of patients
over the past 10 years, the distribution of hip fracture types has
also changed. There has been a steep rise in the number of unstable
extracapsular fractures in the elderly—that is, intertrochanteric
(IT)/subtrochanteric hip fractures—while the number of intracap-
sular hip fractures (that is, femoral neck fractures) has remained
stable7. Pertrochanteric fractures in the region surrounding the
greater and lesser trochanters now account for about half of all
hip fractures in the elderly8,9 and although this may be due in part
to osteoporosis, the underlying reasons are still not entirely clear.
The high expense of treating a hip fracture is known, however.
The average patient with a hip fracture spends $40,000 in the first
year in direct medical costs1,5 and approximately $5,000 in each
of the following years. Despite this tremendous financial burden,
which includes hospital costs, rehabilitation, and nursing care, there
remains a 21 to 30% risk of mortality within 1 year of sustaining
a hip fracture in the elderly population1, a risk up to three times
higher in men compared with women3.
Epidemiology
Surgical treatment for hip fractures in the elderly represents the
standard of care10. Non-operative treatment has resulted in second-
ary fracture displacement of up to 62%; increased medical com-
plications such as urinary tract infections, pneumonia, and deep
vein thrombosis; and poor functional outcomes11. Despite the high
cost of surgical treatment, a recent economic analysis showed that
there is actually a societal benefit to surgery compared with non-
operative management; average savings per patient are $65,279
and $67,964 for displaced intracapsular and extracapsular hip
fractures, respectively. This includes costs offset by continued
nursing home care and long-term medical costs6. Non-operative
management is typically reserved for critically ill patients not medi-
cally stable for surgery or non-ambulatory patients. Although the
goals of treatment in young patients are anatomic reduction and
stable fixation11, the purpose of fixation in the elderly population
focuses more on the restoration of function and a decrease in sec-
ondary complications. Treatment can be accomplished by various
methods but most commonly includes open reduction and internal
fixation (intramedullary versus extramedullary) or arthroplasty12,13.
F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016
Surgical timing
Regardless of the treatment method, there has been a push toward
surgery within 48 hours of hospital admission. Several studies
have examined the correlation between surgical timing and subse-
quent morbidity and mortality in elderly patients14–16. In one meta-
analysis of over 250,000 patients, an operative delay beyond
48 hours resulted in an absolute risk of 41% increased 30-day
mortality rate and a 32% increased odds of 1-year mortality15.
Similarly, in a prospective observational study of 5683 male
veterans over the age of 65 with hip fractures, a surgical delay of
greater than 4 days resulted in a higher mortality risk, especially
in patients in a higher pre-operative risk stratification group16.
Therefore, hip fracture surgery in an elderly patient should be
performed expediently with focused consideration of comorbidities
and post-operative reduction in pain and return to functioning
in order to maximize outcomes.
Intertrochanteric hip fractures
Since its introduction in the 1980s, cephalomedullary fixation for
IT fractures in the elderly has gained popularity. Aside from the
theoretical advantage of being less invasive and biomechanically
superior17–19, these devices have been advocated in cases of unstable
fracture patterns such as reverse obliquity, lateral wall incompe-
tence, subtrochanteric extension, and medial calcar disruption8,20,21.
A review of reverse obliquity fractures in a large Scandinavian
patient registry has corroborated the use of the nail, demonstrat-
ing a higher re-operation rate (6.4% versus 3.8%) at 1 year in the
sliding hip screw (SHS) group compared with the intramedullary
nail group, as well as a higher pain score and lower satisfaction
rating. The lower overall numbers of re-operation may be due to the
addition of a trochanteric stabilization plate to resist femoral shaft
medialization, but this contributes to increased operative time and
may add technical complexity22. In a cross-sectional survey distrib-
uted to practicing orthopedic surgeons, Niu et al. found that 68%
of the 3786 respondents across all levels of experience primarily
used cephalomedullary devices for IT fractures for reasons such
as ease of use, potential improvements in functional outcome, and
biomechanical advantage8. Using a newer-generation long or short
nail does not seem to have an effect on re-operation rate, risk of
periprosthetic fracture, or mortality rate18,20. One potential advan-
tage of using a long nail in the elderly population is that it dis-
perses intramedullary forces and limits diaphyseal stress risers in
already-weak bone. If the device is used as an internal splint of the
entire long bone endoskeleton, the risk of periprosthetic fracture
may be mitigated (Figure 1). However, a cephalomedullary nail
does cost approximately $900 to $1500 more than an SHS. In a cost
analysis of the two implants, Swart et al. found that for stable IT
fractures, the SHS was more cost effective23. This cost may be
partially offset by increased length of stay after SHS fixation24,
but for stable or minimally displaced fractures, the SHS remains a
successful treatment (Figure 2)25.
Subtrochanteric hip fractures
The management of subtrochanteric fractures is challenging
because of the inherent instability of the fracture pattern and
the large muscular deforming forces on the proximal and distal
fragments. Flexion and external rotation of the proximal fragment,
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 F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016

A B C
Figure 1. Pre-operative anteroposterior (A) and post-operative anteroposterior (B) and lateral (C) radiographs of a 94-year-old male who
underwent long intramedullary fixation for a left unstable intertrochanteric hip fracture.

A B C
Figure 2. Pre-operative anteroposterior (A) and post-operative anteroposterior (B) and lateral (C) radiographs of an 87-year-old female who
underwent sliding hip screw fixation for a left stable intertrochanteric hip fracture.

combined with potential comminution of the calcar and adductor
forces medializing the femoral shaft, render reduction difficult. Both
intramedullary and extramedullary devices have been used for these
injuries. Among three level I studies of elderly patients included in
a meta-analysis, the data of Kuzyk et al. favor the more reliable use
of intramedullary devices26. In a more recent meta-analysis compar-
ing intramedullary and extramedullary fixation for subtrochanteric
femur fractures in the elderly, there was an 83% lower relative risk
of revision in the intramedullary nail group and 76% lower rate of
fixation failure in the intramedullary group27. With regard to other
factors, there was no difference in intra-operative blood loss, case
length, and post-operative complications. Moreover, in patients
with comorbidities or osteoporotic bone, intramedullary fixation
for subtrochanteric femur fractures is preferred.
Arthroplasty for hip fractures
Much of the recent advancement in the treatment of hip fracture
and specifically femoral neck fracture surgery in the elderly has

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taken place in the realm of arthroplasty. Several questions arise
when considering joint replacement for fracture: is a total hip
arthroplasty (THA) or hemiarthroplasty (HA) a better option? If HA
is performed, should a unipolar or bipolar device be used? Should
the femoral implant be cemented? Again, the overarching goal is
to allow the fastest recovery with the lowest complication risk.
Bone quality plays a large role in the success of hip fracture fixa-
tion. Patients with osteoporosis have a 30% increased risk of
nonunion when internal fixation is the treatment11. This has resulted
in a plethora of research focused on arthroplasty as an alternative to
replace the osteoporotic bone. A short-term meta-analysis by Gao
et al. evaluated 4508 patients with femoral neck fractures over the
course of a 5-year period13. They reported that compared with inter-
nal fixation, arthroplasty reduced the risk of major complications
and the incidence of re-operation. Pain relief and function were
also improved, but mortality rates were similar. This emphasizes
the tremendous setbacks in quality of life and longevity sustained
after a hip fracture regardless of treatment. In a longer-term meta-
analysis with at least 4 years of follow-up, Jiang et al. similarly
found no difference in mortality between the internal fixation and
arthroplasty groups but did find improved re-operation risk and
mid-term functional improvements after arthroplasty28. Despite the
larger incision and dissection required for arthroplasty, there was no
increased incidence of wound infection. Unique to each treatment
modality, dislocation was higher in the arthroplasty group, whereas
aseptic necrosis and nonunion were more prevalent in the internal
fixation group. Finally, the longest-term meta-analysis of a 15-year
minimum by Johansson reported a 55% failure rate with internal
fixation compared with a 5% failure rate after arthroplasty29. In this
group of 146 hips in patients who were at least 75 years old, there
was also no difference in mortality between the groups. Other stud-
ies have also found a higher risk of revision surgery after inter-
nal fixation and recommend arthroplasty for healthy, lucid elderly
patients30–33. Although the rate of re-operation is lower, it should
A B
Figure 3. Pre-operative anteroposterior (A) and post-operative anteroposterior (B) and lateral (C) radiographs of a 91-year-old female who
underwent an uncemented HA for a displaced, right subcapital femoral neck fracture.
F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016
be recognized that arthroplasty introduces a distinct subset of
complications, namely dislocation, aseptic loosening, infection,
and wound complications.
Total hip arthroplasty vs hemiarthroplasty
Once arthroplasty is the decided treatment, the surgeon must
decide whether a total hip replacement or a partial replacement is
warranted. The Hip Fracture Evaluation with Alternatives of Total
Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial is
underway to attempt to clarify this debate. This is a prospective,
multicenter, randomized trial comparing THA versus HA in patients
at least 50 years old who sustain displaced femoral neck fractures.
The primary outcome is revision surgery rates at 2 years post-
operatively, and functional scores, quality of life, and complications
are secondary outcome measures34. Although this represents the
largest study of its kind, others have elucidated the differences in
treatment options. Pre-operative considerations include the pres-
ence of pre-existing osteoarthritis, medical comorbidities, mental
status, and functional demand. Lower-demand patients may be more
suitable for a HA (Figure 3) given the lower risk of dislocation,
elimination of problems associated with acetabular reaming and
version, and decreased operative time and blood loss; patients with
cognitive dysfunction may not be able to comply with certain hip
precautions, leading to a higher rate of dislocation. Higher-demand
patients may avoid re-operation secondary to acetabular erosion
from a large HA head if they undergo a THA (Figure 4). The
American Academy of Orthopaedic Surgeons Clinical Practice
Guideline (AAOS CPG) on hip fractures in the elderly cites moder-
ate evidence to support a benefit to THA in properly selected patients
with displaced femoral neck fractures. However, the benefits of
lower pain scores and lower revision rates for acetabular wear
may be confounded by a selection bias in that more active, healthy
individuals undergo a THA compared with HA35. Zi-Sheng
et al. conducted a meta-analysis showing that compared with HA,
THA has a lower long-term risk of re-operation rates at 13 years
C
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A B
Figure 4. Pre-operative (A) and post-operative (B) anteroposterior
radiographs of an 81-year-old male who underwent a total hip
arthroplasty for a displaced, left subcapital femoral neck fracture.
post-operatively but not mortality4. However, the rate of dislocation
was higher in the THA group (17.2% versus 4.5%). Similar find-
ings were reported by Hopley et al. in their systematic review of 1890
patients more than 60 years old; the authors cited a 4.4% risk of re-
operation difference in THA compared with HA as well as
better Harris Hip Score (HHS) ratings up to 4 years post-
operatively36. Several other meta-analyses concur with these find-
ings, although there are inherent limitations in using the HHS for
evaluation37–39.
Unipolar vs bipolar hemiarthroplasty
The second point in the HA decision tree is a unipolar or bipo-
lar articulation. Bipolar femoral heads were initially introduced
to decrease acetabular wear and increase hip range of motion to
decrease dislocation rate40–42. The added articulation may also
make conversion to a total hip replacement easier. In a randomized
controlled trial with 4-year follow-up, Inngul et al. evaluated
120 patients over the age of 80 randomly assigned to unipolar versus
bipolar cemented HA43. Patients in the unipolar group displayed a
higher incidence of acetabular erosion at 1 year44, but no significant
differences were seen at the 2- and 4-year time points43. There was
also no difference seen in functional scores or re-operation rates. In
another randomized trial, Kanto et al. showed that patients in the
unipolar group (n = 88) had a higher dislocation rate than the bipo-
lar group (n = 87), but this difference did not translate into increased
revision rates by 8 years post-operatively45. There were no signifi-
cant differences in ambulatory function, early acetabular erosion, or
mortality. The long-term outcome similarities are thought to be due
to a unitization of the bipolar articulation over time, thus rendering
F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016
the construct functionally unipolar40. Despite the risk of acetabular
erosion, the risk of conversion of a bipolar HA to a THA is low
and is similar to the rate of conversion from a unipolar construct.
One study reported that of the 164 included patients, only four
underwent a conversion after 1 year, and only one (0.6%) was
performed for groin pain46. Von Roth et al. analyzed 376 cemented
bipolar HAs and found that the rate of conversion to THA at
20 years was only 3.5% and that only 1.4% were due to cartilage
wear47. Even though an increase in patient age is commensurate
with decreased activity level and thus decreased cumulative wear
over time, no living patient at the endpoint of follow-up showed
cartilage wear or implant loosening47. In the most recent meta-
analysis, Jia et al. again found a lower acetabular erosion rate
within the first year for bipolar articulations but no other significant
differences with regard to mortality, complications, and functional
outcome scores, challenging the hypothesis that the bipolar
prosthesis produced a less painful arthroplasty and improvement
in quality of life42. This review does not explore the rates of
conversion to THA.
Femoral stem fixation: cemented vs uncemented
In both HA and THA, femoral stem fixation remains an area of
controversy. The AAOS CPG on hip fractures in the elderly put
forth moderate evidence in support of cemented femoral stems in
patients undergoing arthroplasty for femoral neck fractures35. Using
cemented fixation results in an overall decrease in periprosthetic
fracture risk30,48 and an improved rate of loosening. In addition,
cement interdigitates well in osteoporotic bone49 and antibiotics
may be mixed into the cement for infection prophylaxis (Figure 5).
Potential disadvantages of cement include increased operative time,
difficulty with extraction in the case of revision, and the risk of
fat embolus or bone cement implantation syndrome (BCIS). With
a steep learning curve, improper cementation technique may also
result in a varus femoral stem, thus putting the prosthesis at risk
for failure.
Data from 19,669 patients in a Scottish registry were evalu-
ated to investigate the mortality associated with cemented fixa-
tion. Cemented HA was associated with a small but significantly
higher rate of mortality than uncemented HA on day zero and up
to day one50. Age was also an independent predictor of mortality.
In specific patient populations, cement is not advised. The mono-
mer from the cement enters the bloodstream during pressurization
and may cause hypotension, thus decreasing cardiac output and
overloading heart function in patients with heart disease. Patients
with decreased pulmonary reserve are at risk for BCIS. If cemen-
tation is undertaken in these patients, it is important to make the
anesthesia team aware of when the cement is being pressurized51.
Lastly, elderly patients have a higher fat-to-marrow ratio, thus
increasing the risk of fat embolism.
When cementation is successful, there may be a lower re-operation
rate in the long term. At 1-year follow-up, Deangelis et al. found
no difference in functional outcomes or acute complications52 when
comparing uncemented and cemented cohorts. However, comparing
re-operation rates among elderly patients undergoing cemented
versus uncemented HA, Viberg et al. found that the cemented cohort
had a decreased hazard ratio and a superior long-term implant sur-
vival rate after 3 years compared with the uncemented group53.
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A B
Figure 5. Pre-operative anteroposterior (A) and post-operative anteroposterior (B) and lateral (C) radiographs of a 79-year-old male with
metastatic prostate cancer who underwent a right cemented hip hemiarthroplasty for a pathologic femoral neck fracture.
A Norwegian registry of 11,116 HAs evaluated in a prospective
observational study showed that at 5-year follow-up, uncemented
HA had a 2.1-fold increased risk of revision, most commonly for
periprosthetic fracture. In keeping with the intra-operative com-
plications of cementation noted above, there was a higher risk
of intra-operative mortality in their cemented group, although
longer-term mortality risk was not significantly different30. These
studies, however, do not account for the fact that patients in the
cemented group may have inferior bone quality, which may be
a surrogate marker for other comorbidities. In a study by Taylor
et al., HA with a cemented implant provided a comparable outcome
to the uncemented group in patients without severe cardiac dis-
ease, although there was a trend toward better function and mobil-
ity in the cemented group49. Both groups, however, displayed an
approximately 18 to 24% decrease in independence when compared
with their pre-operative level of functioning49. Thus, it is impor-
tant to evaluate the patient in terms of functional capacity but also
medical stability prior to deciding whether a cemented prosthe-
sis is the best option. In otherwise-healthy, elderly patients with
osteoporosis, cemented HA is a good option in terms of post-
operative pain and re-operation rates.
Anesthesia considerations in hip surgery
A comprehensive pre-operative evaluation by the anesthesia team
also plays a large role in the type of anesthesia used during surgery
and has significant implications in the patient’s immediate post-
operative recovery. The use of spinal versus general anesthesia, the
two most common anesthetic modalities in hip fracture surgery, and
the use of peripheral nerve blocks have entered into the research
spotlight over the past several years. Prompting a large prolifera-
tion of research in this area, a 2011 review by the UK National
Clinical Guideline Center examined a group of 22 trials and
F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016
C
concluded that no recent randomized trial had been able to fully
address or appreciate the differences between general and neurax-
ial anesthesia for hip fractures54. Few studies since that time have
shown a trend toward lower delirium rates, complications, and mor-
tality associated with regional anesthesia55,56, and other older studies
were unable to demonstrate any significant differences in mortality
beyond 2 months57–61. Furthermore, these studies have influenced the
opinions of various subspecialty associations that continue to spur
debate in this arena35. An important consideration arises in patients
with more significant illness or comorbidities who may be subject
to a selection bias favoring regional anesthesia, potentially overes-
timating the association between specific anesthesia techniques and
patient outcomes62. To this end, the REGAIN trial (Regional versus
General Anesthesia for Promoting Independence after Hip Fracture,
NCT02507505) now underway is examining the effects of general
versus spinal anesthesia on post-operative mobility and overall health
status following hip fracture surgery in elderly patients. REGAIN
will randomly assign 1600 patients across about 30 hospitals in the
US and Canada to spinal versus general anesthesia over 3.5 years,
and the goal is to provide a stronger evidence base going forward to
inform treatment decisions among patients with hip fracture.
The addition of peripheral nerve blocks has aided in pain
reduction after hip fractures as well as limiting post-operative
psychological complications such as delirium in the elderly popula-
tion. Seen in approximately 10 to 16% of elderly surgical patients,
delirium is associated with delayed rehabilitation, prolonged hos-
pital stay, and poorer functional outcomes63. A 2002 Cochrane
review of eight trials demonstrated that nerve blocks resulted in a
reduction in the amount of oral and parenteral analgesics admin-
istered post-operatively64. In corroboration, several studies have
reported a reduction in pre-operative pain or delirium (or both)
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following either femoral nerve or fascia iliaca blockade63,65. Foss
et al. reported on 48 patients with hip fractures randomly assigned
to mepivacaine fascia iliaca blocks or placebo injections65. Those
in the placebo group received intramuscular rescue doses of mor-
phine. The authors reported that pain relief was superior at all
time points in patients who received the block and that sedative
risk was increased in the placebo group receiving morphine65.
Patients may even be able to receive these blocks in the emergency
department almost immediately after they arrive, and this may
decrease their total narcotic use prior to surgery. In a small, pro-
spective observational study, elderly patients receiving blocks
in the emergency department reported a decrease in pain, up to
67%, only 30 minutes after the block was administered. The pain
scores were unchanged up to 4 hours post-operatively66. Regard-
ing the efficacy of two blocking options, Newman et al. conducted
a comparison of pre-operative femoral nerve versus fascia iliac
compartment blocks in patients with femoral neck fractures67. The
authors showed that though requiring more time to administer and
slightly more expensive, femoral nerve blocks result in a greater
reduction in pain according to the visual analogue scale.
Post-operative care
Post-operatively, hemodynamic stability serves as an additional
barometer of earlier participation in rehabilitation and potentially
a quicker hospital discharge. Perhaps the most robust study in
this area is a follow-up to the trial of transfusion requirements in
critical care patients. A 2011 randomized controlled trial of 2016
patients across 47 clinical sites compared a conservative transfusion
threshold (8 g/dL) versus a more liberal one (10 g/dL) in elderly
patients with a history of cardiovascular disease (or risk factors)
and a hip fracture. Patients in the liberal group were given red blood
cell transfusions to maintain a hemoglobin level of 10 g/dL. Patients
in the conservative group required a hemoglobin level of 8 g/dL or
below and symptoms of anemia to receive a transfusion. The pri-
mary outcome measure was the ability to walk 10 feet unassisted at
60 days’ follow-up. Carson et al. showed that there was no evidence
to support a more liberal transfusion strategy in patients with hip
fracture68. This study not only has cost implications but may allow
patients to be mobilized more quickly, decreasing hospital length of
stay and complications associated with prolonged hospitalization.
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of each procedure, there are several overarching themes. Pre-
operative regional blocks and post-operative multimodal anesthe-
sia have been shown to be highly effective in pain management
and narcotic reduction. Further studies should focus on elucidat-
ing these trends post-operatively. Displaced femoral neck fractures
in active, otherwise-healthy elderly patients are best treated with
a THA, especially if they have pre-existing groin pain consistent
with osteoarthritis. Lower-demand patients may be better suited
to a HA, and a cemented, unipolar arthroplasty is the current
treatment of choice. With further advances in implant design,
risks such as component wear and dislocation may be mitigated.
For unstable IT or subtrochanteric fractures, the fracture pattern
largely determines the implant choice.
Author contributions
Joshua Rozell and Mark Hasenaur reviewed the literature and
prepared the first draft of the manuscript. Derek Donegan and Mark
Neuman conceived the review. All authors were involved in the
revision of the draft and read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Grant information
The author(s) declared that no grants were involved in supporting
this work.
F1000 recommended
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 F1000Research 2016, 5(F1000 Faculty Rev):1953 Last updated: 11 AUG 2016

Open Peer Review

Current Referee Status:

Editorial Note on the Review Process

F1000 Faculty Reviews are commissioned from members of the prestigious F1000 Faculty and are edited as a
service to readers. In order to make these reviews as comprehensive and accessible as possible, the referees
provide input before publication and only the final, revised version is published. The referees who approved the
final version are listed with their names and affiliations but without their reports on earlier versions (any comments
will already have been addressed in the published version).

The referees who approved this article are:

Version 1

1 Ian Moppett, The University of Nottingham, Nottingham, UK

Competing Interests: No competing interests were disclosed.

2 Stephen Kates, Virginia Commonwealth University Health System, Richmond, VA, USA
Competing Interests: No competing interests were disclosed.

F1000Research
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